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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320283
Report Date: 05/27/2022
Date Signed: 06/07/2022 05:07:13 PM

Document Has Been Signed on 06/07/2022 05:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:VERNON COTTAGEFACILITY NUMBER:
198320283
ADMINISTRATOR:UMANA, JOSEFACILITY TYPE:
740
ADDRESS:2312 ROSWELL AVETELEPHONE:
8186066136
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY: 6CENSUS: DATE:
05/27/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Jose UmanaTIME COMPLETED:
12:30 PM
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Licensing Program Analysts (LPAs) Jade Jordan, made an announced visit, and met with the Applicant /Administrator Jose Umana to conduct a Pre-Licensing evaluation on Friday May 27, 2022, at10:10 Am.

An application was submitted to Community Care Licensing Department (CCLD) on 03/08/2022 for an initial application to serve Individuals over ages 60 years. The requested capacity is for Six (6) Non-ambulatory clients, and (1) bedridden clients, total capacity of Six (6). Structure: Facility is a one-story family home with Seven (7) bedrooms, (3) full bathrooms, (1) half bathroom, living room, TV room, and kitchen. Washer/Dryer appliances are located locked laundry storage space located to the right of the kitchen. A one (1) car locked garage is located in the front of the property, will be used for storage inaccessible to Residents. Front yard landscape is in good condition at time of visit. Bedroom Residents: There shall be no more than two residents per bedrooms. Bedrooms #1-5 are for non-ambulatory clients. Bedroom #6 will be for bedridden client. Furniture was observed for all resident rooms, they will be equipped with one bed, night stand, chair, overhead lightning. Bedroom Staff: There will be no live-in staff. Bathrooms: Three (3) bathrooms have a working toilet, wash basin, bath-tub/shower. There are 3 bathrooms that will accommodate non-ambulatory residents. 1 1/2 designated for staff and vistors. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, fitted sheet, blanket and bedspreads, all rooms have required mattress pads. Ample supply of linen will be stored in the closet hallway.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE: DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: VERNON COTTAGE
FACILITY NUMBER: 198320283
VISIT DATE: 05/27/2022
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Emergency Phone Numbers, Exit Plan, & Menu: Emergency numbers are not yet posted, will be posted in the Living room area. Facility will have a land line telephone located in the Dining room area not yet active. Two (2) fully charged fire extinguishers are in the kitchen, and hallway. Food Service: Dishes, and flatware will be stored in the kitchen cupboards, inspected and in good repair. Ample food supply is stored in the kitchen and consists of the following: 7-day non-perishables. Dishwasher in kitchen properly installed and functioning. Smoke Detectors/Carbon Monoxide(s): There are electrical & connected smoke detectors and carbon monoxide; located throughout the facility fully operational. Appliances: Stove burners (gas) oven, and washer/dryer are in working condition. There is one (1) refrigerator in the home; located in the kitchen. The residence is equipped with central heat/air conditioning; and water heater located in locked laundry room. Toxins: Cleaning supplies, and toxins will be located in locked laundry/hall way cabinet only accessible to staff.

Temperature: Hot water was measured at # 120.d which is within normal limits (105-120 degrees). Medication, First-Aid Kit & Book: Designated centrally stored medication will be locked and located in the locked hall way cabinet.. Sufficient bandages, one (1) tweezer, one (1) thermometer, one (1) First Aid Manual, and one (1) pair of scissors. Clients & Staff Files: Designated area for files will be located in locked office file cabinet. Applicant will not handle cash resources of clients. Reading Material, Games, Equipment & Materials: The facility will have board games, books, and other recreational materials for the client's use. Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises. Fire Clearance: Fire clearance was approved on 05/03/2022 does not advise of any delayed egress features and/or any locked perimeters.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: VERNON COTTAGE
FACILITY NUMBER: 198320283
VISIT DATE: 05/27/2022
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Component III:
Component III was completed at the Pre-Licensing on Friday, 05/27/2022. Information provided about how to operate the facility within substantial compliance. The following individuals Jose Umana, Administrator participated. When the applicant /administrator was asked if they have understood Title 22 he responded in the affirmative.

During the pre-licensing inspection certain items were observed which do not comply with applicable laws and regulations; the following items must be corrected, and proof of correction shall be submitted to the CCLD office to the attention of LPA by 05/31/2022. If additional time is required to complete noted

items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction.



1. Cameras in bedrooms taken out
2. Required Postings
3. Curtain Rods
4. Shower Mats
5. Patio Furniture
6. Window Screen
7.Telephone


An exit interview was conducted, and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
LIC809 (FAS) - (06/04)
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